Biofeedback is superior to electrogalvanic stimulation and massage for treatment of levator ani syndrome

Abstract

Background & aims: Levator ani syndrome (LAS) might be treated using biofeedback to teach pelvic floor relaxation, electrogalvanic stimulation (EGS), or massage of levator muscles. We performed a prospective, randomized controlled trial to compare the effectiveness of these techniques and assess physiologic mechanisms for treatment.

Methods: Inclusion criteria were Rome II symptoms plus weekly pain. Patients were categorized as "highly likely" to have LAS if they reported tenderness with traction on the levator muscles or as "possible" LAS if they did not. All 157 patients received 9 sessions including psychologic counseling plus biofeedback, EGS, or massage. Outcomes were reassessed at 1, 3, 6, and 12 months.

Results: Among patients with "highly likely" LAS, adequate relief was reported by 87% for biofeedback, 45% for EGS, and 22% for massage. Pain days per month decreased from 14.7 at baseline to 3.3 after biofeedback, 8.9 after EGS, and 13.3 after massage. Pain intensity decreased from 6.8 (0-10 scale) at baseline to 1.8 after biofeedback, 4.7 after EGS, and 6.0 after massage. Improvements were maintained for 12 months. Patients with only a "possible" diagnosis of LAS did not benefit from any treatment. Biofeedback and EGS improved LAS by increasing the ability to relax pelvic floor muscles and evacuate a water-filled balloon and by reducing the urge and pain thresholds.

Conclusions: Biofeedback is the most effective of these treatments, and EGS is somewhat effective. Only patients with tenderness on rectal examination benefit. The pathophysiology of LAS is similar to that of dyssynergic defecation.

Keywords: Biofeedback; Dyssynergic defecation; Electrogalvanic stimulation; Proctalgia.

Conflict of interest statement

Conflict of Interest: No authors have a conflict of interest with respect to this manuscript.

2010 AGA Institute. Published by Elsevier Inc. All rights reserved.

Figures

Figure 1

Flow chart showing the disposition of all subjects considered for the trial.

Figure 2

Number of pain days for the previous month. Dark gray bars are Biofeedback-treated patients, light gray bars are EGS-treated patients, and white bars are patients treated with digital massage and sitz baths. Vertical lines show 95% confidence intervals. Patients with a highly likely diagnosis of LAS are shown separately from patients with only a possible diagnosis. *Significantly different from the Biofeedback group at p#significantly different from the EGS group at p<0.025.

Figure 3

Average of weekly pain intensity rating for previous month. Pain was rated on a 10cm visual analog scale for the worst rectal pain in the previous week. Dark gray bars are Biofeedback-treated patients, light gray bars are EGS-treated patients, and white bars are patients treated with digital massage and Sitz baths. Vertical lines show 95% confidence intervals. Patients with a highly likely diagnosis of LAS are shown separately from patients with only a possible diagnosis. *Significantly different from the Biofeedback group at p#significantly different from the EGS group at p<0.025.

Figure 4

Percent reporting adequate relief at follow-up. Dark gray bars are Biofeedback-treated patients, light gray bars are EGS-treated patients, and white bars are patients treated with digital massage and sitz baths. Vertical lines show 95% confidence intervals. Patients with a highly likely diagnosis of LAS are shown separately from patients with only a possible diagnosis. *Significantly different from the Biofeedback group at p#significantly different from the EGS group at p<0.025.

Figure 5

Subjective change in pain, rated -2 for “a lot worse”, -1 for “a little worse”, 0 for “same as before”, +1 for “a little better”, +2 for “fairly better”, and +3 for “a lot better or cured”. Dark gray bars are Biofeedback-treated patients, light gray bars are EGS-treated patients, and white bars are patients treated with digital massage and sitz baths. Vertical lines show 95% confidence intervals. Patients with a highly likely diagnosis of LAS are shown separately from patients with only a possible diagnosis. *Significantly different from the Biofeedback group at p#significantly different from the EGS group at p<0.025.